Quality improvement

The hospital shall have an ongoing, facilitywide, written quality improvement program and risk management program approved by the governing body with implementation plans that evaluate and improve the quality of patient care, governance, and managerial and support activities. 1. The general acute hospital shall develop and implement a quality improvement program for assessing and improving quality which describes objectives, organization, scope, and mechanisms for overseeing the effectiveness of monitoring, evaluation, and improvement activities. a. The quality improvement program must include a written plan for all services including indicators of care which are important to the health and safety of the patients. b. The indicators of the written quality improvement plan must relate to the quality of care and must be objective, measurable, and based on current knowledge and clinical experience. c. Written documentation of the quality improvement activities and risk management activities must be prepared and reported through established channels to the governing body at least four times a year. 2. Primary care hospitals are subject to the quality improvement requirements for general acute hospitals in this section. 3. Specialized hospitals are subject to the quality improvement requirements for general acute hospitals in this section.